EVIDENCE-BASED MEDICINE

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Transcript of EVIDENCE-BASED MEDICINE

EVIDENCE-BASED MEDICINEClinical Scenario50/F came in for follow up with lab results.

Hypertension Stage 2Diabetes Mellitus Type 2 Suspect Obese Class IDilemmaIn my patient who is 50 years old with type 2 diabetes and cardiovascular disease is it safe to target the normal HbA1c level of 6%?

QuestionIn patients 40 years and older with Type 2 diabetes and cardiovascular disease or cardiovascular risk factors will a target glycated hemoglobin of <6.0% result in more deaths due to cardiovascular causes than a target glycated hemoglobin of 7.0-7.9% in a randomized controlled trial?

Are the defined groups of patients similar – other than through their exposure status to the treatment under study?

Were participants and researchers blinded to the measures of interest?

Intention-to-treat analysesMean of 3.7 years of an intensive glycemic intervention on cardiovascular diseaseMean of 1.2 years of standard glycemic therapy

Was the follow-up period sufficiently long and complete?

Do the results satisfy some “diagnostic tests for causation”?

STUDY RESULTS

What is the magnitude of the association between the exposure and the outcome?

Relative Risk

= Rt – Rc= 0.037 – 0.029= 0.008

Absolute Risk Increase (ARI)

=1/ARI= 125

NUMBER NEEDED TO HARM(NNH)

Confidence interval 95% p Value = 0.02

HOW PRECISE WAS THE ESTIMATE OF TREATMENT EFFECT?

Can the results be applied to my patient care?

Blood pressure and dyslipidemia were also managed in the study and there were no significant interactions noted between the glucose-lowering study and the blood-pressure study or between the glucose-lowering study and the lipid study.

Were all clinically important outcomes considered?

In one meta-analysis of glucose lowering studies, they suggested that multifactorial interventions by aggressive management of hypertension, dyslipidemia and hyperglycemia, use of aspirin, and cessation of smokingshould be the goal of therapy in Diabetes Type 2 patients with cardiovascular risk factors.What alternative treatments are available?

The results of the ACCORD trial show that in persons who have a high risk of cardiovascular disease and suboptimally controlled, long-standing diabetes and intensive therapeutic approach targeting normal glycated hemoglobin levels is associated with higher mortality. CONCLUSION

Boussageon, R., et al., Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: meta-analysis of randomised controlled trials. BMJ 2011;343:d4169.HbA1c goal of <7% has been shown to reduce microvascular complications of diabetes and if implemented soon after the diagnosis of diabetes is associated with long-term reduction in macrovascular disease.<6.5% HbA1c goal for selected individuals, if it can be achieved without significant hypoglycemia. these might include those with short duration of diabetes, long life expectancy and no significant cardiovascular disease.<8% Hba1c goal for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions and long-standing diabetes.American Diabetes Association: Standards of Medical Care in Diabetes - 2013